MEDICARE: MS. SUZANNE MARIE ETHERIDGE MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFC40453	CA

General Provider Information

NPI Number	:	1205931912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUZANNE MARIE ETHERIDGE MFT

Provider Business Mailing Address
First Line	:	23272 MILL CREEK DR
Second Line	:	#150
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-1641
Country	:	US
Telephone Number	:	949-829-3945
Fax Number	:	714-669-1237

Provider Business Practice Location Address
First Line	:	23272 MILL CREEK DR
Second Line	:	#150
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-1641
Country	:	US
Telephone Number	:	949-829-3945
Fax Number	:	714-669-1237

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	03/22/2013

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